MEDICAL LABORATORY SCIENCES PROGRAM
MSC09 5250
1 University of New Mexico
Albuquerque, NM 87131-0001
(505) 272-5434
APPLICATION FOR ADMISSION
Deadlines for Application: (please mark date applying for)
June 15 for August
October 15 for January
1.Full Legal Name: ______
(last) (first) (middle initial)
2.Social Security Number: ______(UNM Student ID #:______)
3.CurrentPermanent
Address: ______Address: ______
______
(city)(city)
______
(state)(zip code)(state) (zip code)
Telephone Number: ______Telephone Number: ______
E-mail Address: ______
4.Name and address of person to be contacted in case of emergency:
______Day Time
Telephone Number: ______
______
______
5.Date of Birth (optional): ______
6.Are you a New Mexico resident? Yes No
7.Are you a United States citizen? Yes No
If foreign, indicate country: ______If immigrant, give your Alien Registration #:
Visa type: ______- _ _ _ - _ _ _
8.Were you ever convicted of a felony? If yes, explain, giving dates:
Yes No
9.Secondary Education:
High School(s) / City / State / Graduation DateInstitutions / City/State / Dates of Attendance
From / To / Degree
10.List all colleges and universities attended and degree(s) earned. Official transcripts from all institutions listed below must be sent to Medical Laboratory Sciences.
11.Degree status (check and complete appropriate answer):
I have a baccalaureate degree prior to entering the Medical Laboratory Sciences Program.
University granting degree: ______
I plan to receive the BSMLS degree after completing the Medical Laboratory Sciences Program.
University to award degree: ______
12.List courses now in progress and/or planned prior to starting the Medical Laboratory Sciences Program. Specify credit hours and completion dates for these courses.
13.Explain interruptions, if any, in your college education other than vacations.
14.List any honors received while in college.
15.List any extracurricular, community, or avocational activities you participated in while in college. (Supplying this information is optional.)
16.List all employment in the last three years include the following:
Date / Employer / Hours/Week / Job Title
17.Have you ever performed volunteer work in a hospital or clinical laboratory?
Yes No
18.Briefly explain why you want to become a medical technologist.
19.Do you plan to attend as a part-time student if accepted into this program?
Yes No
20.Please list three references (employers and/or professors) who can evaluate your ability and aptitude for this type of career. Complete the top portion of the attached recommendation forms before giving them to the below named individuals.
Recommendations are due at Medical Laboratory Sciences by the deadline listed below.
Name / Occupation / AddressDEADLINE: Application must be postmarked by:
June 15 to be considered for August admission
October 15 to be considered for January admission
I certify that information on this application is complete and accurate to the best of my knowledge. I agree to abide by the policies and regulations of the University of New Mexico.
Signature: ______Date: ______
To comply with ADA and the Rehabilitation Act of 1973, UNM provides this publication in alternative formats. If you have special needs and require an auxiliary aide or service contact the Med Lab Sciences Program, Health Sciences & Services Bldg., Room #217, (505) 272-5434.